Form Ssa 371 – Fill Out and Use This PDF

	Form Approved
SOCIAL SECURITY ADMINISTRATION	OMB No. 0960-0742

Request for Reinstatement - Title II

Wage Earner's Name

I request reinstatement of my Social Security Disability Benefits. I am disabled and my impairment is the same as (or related to) the impairment which was the basis for my prior entitlement. I am not performing substantial gainful activity (SGA) and my medical condition prevents me from performing SGA.

I understand that I may be able to receive provisional (temporary) benefits while my request for reinstatement is being decided.

For persons who have extended medicare coverage :

I understand that my Medicare coverage (Part A hospital insurance and Part B medical insurance) could terminate if my request for reinstatement is denied.

For persons who are entitled to any other SSA benefits based on disability or blindness:

I understand that if SSA denies my request for reinstatement because I have medically improved, my current entitlement to SSA benefits will be reviewed and may terminate.

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

Address (Number and Street)

WITNESSES (Write in ink)

Witnesses are required ONLY if this request has been signed by mark (x) above. If signed by mark (x), two witnesses to the signing who know the applicant must sign below, giving their full addresses.

Form SSA-371 (08-2013) Destroy Prior Editions

(OVER)

THIS INFORMATION IS ONLY NEEDED IF YOUR PROVISIONAL BENEFITS WILL BE SENT TO YOUR

PRIOR REPRESENTATIVE PAYEE

REPRESENTATIVE PAYEE (Write in ink)

Address (Number, Street)

Privacy Act Statement

Request for Reinstatement – Title II

Sections 202(b), 202(c), 202(d), 202(e), 202(f), 205(a), 223 and 1872 of the Social Security Act, as amended, authorizes us to collect this information. We will use the information you provide to determine if you or your dependents are entitled to insurance coverage and/or benefits. Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from making an accurate decision on your request and could result in the loss of insurance coverage and benefits.

We rarely use the information you supply for any purpose other than the reason stated above. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with

approved routine uses, which include but are not limited to the following:

1.To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans’ Affairs);

3.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;

and,

4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity

and improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information is available in our System of Records Notice entitled, Claims Folders Systems,

60-0089. This notice, additional information regarding this form, and information regarding our systems and programs, are available on-line at www.socialsecurity.gov or at any local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 2 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local

Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form SSA-371 (08-2013)